Many of the new Patient Protection and Affordable Care Act (PPACA) major medical plans are more generous than they look.
They may have deductibles of up to $6,600 for an individual and $13,200 for a family, but many of them cover in-network office visits without requiring patients to meet the deductible.
Analysts at Breakaway Policy Strategies look at how PPACA plan deductibles actually work in a report on physician visit cost-sharing published by the Robert Wood Johnson Foundation and based on a large batch of 2014 and 2015 health plan data posted on the foundation’s website.
The full spreadsheets include data on all silver-level PPACA exchange plans.
The Breakaway analysts prepared separate analyses based on silver exchange plans in the 10 states with the highest PPACA exchange plan enrollment: Florida, California, Texas, North Carolina, Georgia, Pennsylvania, New York, Virginia, Illinois and Michigan.
For a look at what the analysts said about deductibles in the physician visit cost-sharing report, read on.
1. A majority of silver plans pay for ordinary in-network sick care before an enrollee has met the deductible.
Analysts found that, in the 10 states they studied, only 28 percent of the silver exchange plans require patients to meet their deductibles before getting coverage for primary care provider office visits.
That’s down from 30 percent in 2014.
In most of the plans studied, enrollees can get coverage for a sick visit to an in-network primary care provider without meeting the deductible, by paying a co-payment, a coinsurance amount or both a co-payment and a coinsurance amount.
In-network primary care co-payments in the 10 states ranged from $5 to $60.
Coinsurance percentages ranged from 20 percent to 50 percent.
Silver exchange plans were more likely to impose deductibles on in-network specialist visits, but not that much more likely: The percentage of silver exchange plans imposing deductibles on in-network specialist visits in the states studied has dropped to 39 percent this year, from 41 percent in 2014.